9 Annex 2: Stakeholder engagement On 8 July 2014, we publicly announced the launch of the project and invited views from patients, patient groups, commissioners, GPs, providers of adult hearing services and other interested parties on how choice and AQP are working in adult hearing services. 1 A questionnaire was developed to help guide stakeholders submissions, which was available online and in hard copy. The consultation closed on 4 September Throughout the project, we also spoke to a broad range of stakeholders with an interest in adult hearing services, including patient groups, commissioners, providers and professional bodies. Some had submitted evidence to the project and we wanted to follow-up on particular points raised. We also spoke to some who had not made a submission to ensure their experiences and views were captured in the project. We also visited a number of providers hearing clinics. As a result of this engagement, we gathered views from: around 390 patients, including patients living in areas where choice had been introduced in adult hearing services and those where it had not 12 patient groups and hearing loss charities, including those operating at both the national and/or local level 33 commissioners, many of which had decided to introduce choice in adult hearing services 110 providers (including their representative bodies), including a broad range of NHS providers, social enterprises, independent sector and third sector providers. Some operate at a national and/or local level, and in areas with and/or without choice 30 GPs, including GPs in in areas where commissioners had introduced choice and in areas where they had not around 40 other stakeholders. We list below those patient groups and charities, commissioners, providers and other stakeholders with whom we engaged and who were content to be named. Some stakeholders provided views anonymously and asked us not to name them, so are not listed below. Patient groups and charities Action on Hearing Loss Age UK Cambridgeshire Hearing Help 1 See: 9

12 Stockport CCG Waltham Forest CCG Other stakeholders AQP Support Hub British Academy of Audiology British Society of Audiologists British Society of Hearing Aid Audiologists Department of Health National Community Hearing Association NHS Clinical Commissioners NHS England NHS Partners Network Public Health England Royal College of Physicians Shropshire Deaf and Hard of Hearing Forum Thorpe Salvin Luncheon Club UKAS 12

13 Annex 3: Case studies examining how the introduction of choice has impacted patients access to services In this annex, we set out our analysis exploring whether introducing patient choice has: improved the accessibility of services by moving them closer to people s homes increased the number of providers and service locations that patients could choose from. We explore four different geographic areas of England where patient choice has been introduced by the respective local commissioners: NHS North Norfolk CCG, NHS South Norfolk CCG and NHS Norwich CCG NHS Brighton and Hove CCG NHS Oxfordshire CCG NHS South Tees CCG and NHS Hartlepool and Stockton-on-Tees CCG. Below, we describe the methodology adopted for this research. Methodology (a) The impact of choice on the accessibility of adult hearing services As a measure of accessibility, we examine the change in the proximity of services to patients homes. In our view, this is likely to be an important driver of accessibility for services like adult hearing services which are used by an older segment of the population. The patient survey results suggest that ease of getting to services is valued by patients and can be an influential factor in their choice of provider. 2 We assume for the purposes of the analysis that the shorter the distance between patients and an adult hearing service provider site, the easier the service is to get to. We use the location as a proxy for patients homes since patients are likely to choose a practice that is close to home. As a measure of accessibility, we examined how many GP were within a particular drive-time of at least one provider s site. We did so both before and after the introduction of patient choice. This allows us to understand the impact of introducing choice on accessibility. 2 See the patient survey report, pages (see also Figure 14). 13

14 We used different drive-time thresholds for urban and rural areas to reflect the willingness of patients to travel further for treatment in rural areas. 3 (b) The impact of choice on the options available to patients In order to measure how the introduction of choice has affected the options available to patients, we identified the number of provider organisations and sites located within a particular drive-time from patient locations. Again, we used GP as a proxy for patient locations, and we used different drive-time thresholds for urban and rural areas. The impact of choice on the accessibility of adult hearing services This section sets out the results of our analysis on ease of access in each of the four areas analysed. North Norfolk, South Norfolk and Norwich CCGs North Norfolk, South Norfolk and Norwich CCGs were originally part of a wider commissioning area overseen by Norfolk Primary Care Trust (PCT). 4 For this wider area and prior to the introduction of patient choice, four providers of adult hearing services operated from five sites. In May 2013 (shortly after the establishment of CCGs), North Norfolk, South Norfolk and Norwich CCGs jointly introduced patient choice in adult hearing services. As a result, six organisations provide the service from 32 sites; the Outside Clinic, a domiciliary care provider, is also available to patients. 5 Figure 1 (overleaf) shows the location of providers sites both before and after patient choice was introduced. Figure 2 (also overleaf) shows the location of the 89 GP in the area and illustrates their proximity to providers sites both before and after the introduction of choice. 6 The actual number located within a 20-minute drive time both before and after the introduction of choice is presented in Table 1. Our analysis shows that the proportion within a 20-minute drive of a provider s site has increased from 53% to 92% of following the introduction This does not imply that patients would not travel a longer distance if necessary; the overall assumption is that patients are better off if they travel shorter distances to access the same service. We have calculated drive-times using Cadcorp SIS software. Norfolk PCT also included West Norfolk CCG. The geographic boundaries of the former PCT were slightly different than the area represented by these four CCGs. Five providers qualified and eventually mobilised for the service under the patient choice framework. Two additional providers in neighbouring CCGs are available to patients. We understand that the CCGs sought to qualify further providers in the summer of 2014 and two additional providers are likely to be available to patients in the future. GP lists for each of the four areas analysed in this appendix were obtained from the Health and Social Care Information Centre (HSCIC) data on GPs, GP Practices, Nurses and Pharmacies. 14

15 of patient choice. This suggests that accessibility has increased significantly following the introduction of patient choice. Table 1: North Norfolk, South Norfolk and Norwich CCGs Before the introduction of patient choice providers in the area providers sites Number within a 20-min drive of a provider s site (53%) After the introduction of (92%) patient choice Note: a total of 89 GP operate in the area The above analysis does not recognise the presence of the Outside Clinic, which started to provide a domiciliary service in the area following the introduction of choice. We expect its presence to improve the overall accessibility of the service even further, especially for housebound patients. 15

17 Figure 2: North Norfolk, South Norfolk and Norwich CCGs accessibility before and after patient choice was introduced (GP within a 20-minute drive away of providers sites) 7 Before the introduction of patient choice After the introduction of patient choice Providers before patient choice Id Providers after patient choice Id Norfolk and Norwich University Hospitals NHS FT 1,2 Norfolk and Norwich University Hospitals NHS FT 1,2 James Paget University Hospitals NHS FT 3 James Paget University Hospitals NHS FT 3 The Queen Elizabeth Hospital Kings Lynn NHS FT 4 The Queen Elizabeth Hospital Kings Lynn NHS FT 4,24,25 West Suffolk NHS FT 5 West Suffolk NHS FT 5 Specsavers 6,11,18,20, 21,26,27 Scrivens 7,8,9,10,12,13,14,15,16,17, ,28,29,30,31,32 7 The map above identifies the full range of sites contracted by North Norfolk, South Norfolk and Norwich CCGs. It therefore includes sites that are contracted to provide services to patients within North Norfolk, South Norfolk and Norwich CCGs but which are located in other CCGs. For clarity we have not conducted an assessment of accessibility to adult hearing services for patients in these neighbouring areas. We expect such an assessment would identify a range of sites not contracted by North Norfolk, South Norfolk and Norwich CCGs which are not included in the map above. 17

18 Brighton and Hove CCG Brighton and Hove CCG broadly covers the same geographical area as Brighton and Hove City Teaching PCT. As a PCT, the commissioning body contracted with Brighton and Sussex University Hospitals NHS Trust for the provision of adult hearing services. The trust operated the service from six different sites, some of which were located outside of the PCT s boundary. With the introduction of patient choice in February 2013, the local NHS trust decided not to apply for the provision of adult hearing services 8 and three new providers were qualified for the service. These new providers offer services from seven sites in the area. Figure 3 (overleaf) shows the location of providers sites both before and after the introduction of choice. Figures 4 and 5 (overleaf) show the location of the 54 GP in the area and illustrates their proximity to providers sites both before and after the introduction of choice. The actual number within a 10-minute and 5-minute drive of a provider s site is presented in Table 2. Our analysis shows that the proportion of within a 10-minute drive of a provider s site has increased from 93% to 98% following the introduction of choice. Similarly, the proportion of within a 5-minute drive has increased from 65% to 81% following the introduction of choice. Table 2: Brighton and Hove CCG Before the introduction of patient choice providers in the area providers sites Number within 10-min drive of a provider s site Number within 5-min drive of a provider s site (93%) 35 (65%) After the introduction of (98%) 44 (81%) patient choice Note: a total of 54 GP operate in the area Our results suggest that accessibility has increased slightly as a result of patient choice in the Brighton and Hove CCG area. This has occurred despite the sole provider at the time of introducing choice deciding not to apply for the provision of adult hearing services. 8 Brighton and Sussex University Hospitals NHS Trust keeps treating the patients they supplied with hearing aids prior to the introduction of patient choice. They will treat these patients for three years following the start of the pathway. After three years they will refer the patients back to the GP. 18

20 Figure 4: Brighton and Hove CCG - accessibility before and after patient choice was introduced (GP within a 10- minute drive away of providers' sites) 9 Before the introduction of patient choice After the introduction of patient choice Providers before patient choice Id Providers after patient choice Id Brighton and Sussex University Hospitals NHS FT 1-6 Specsavers 1,3 Inhealth 2 Bloom Regional Hearing Specialists 4,5,6,7 9 The map above identifies the full range of sites contracted by Brighton and Hove CCG. It therefore includes sites that were contracted to provide services to patients within Brighton and Hove CCG but which are located in other CCGs. For clarity we have not conducted an assessment of accessibility to adult hearing services for patients in these neighbouring areas. We expect such an assessment would identify a range of sites in these neighbouring areas, but who are not contracted by Brighton and Hove CCG (and hence not included here). 20

22 Oxfordshire CCG Before the introduction of patient choice, two providers delivered services in Oxfordshire from 13 sites. 11 As a result of the introduction of patient choice in March 2013, four organisations provide the service from 30 sites; the Outside Clinic, a domiciliary care provider, is also available to patients. Figure 6 (overleaf) shows the location of providers sites both before and after choice was introduced. Figures 7 and 8 (overleaf) show the location of the 99 GP operating in the area and their proximity to providers sites both before and after the introduction of choice. The actual number located within 20-minute and 10-minute drives of a provider s site is presented in Table 3. Our analysis shows that the proportion of within a 20-minute drive of a provider s site has increased from 90% to 99% following the introduction of patient choice. Similarly, the proportion within a 10-minute drive time increased from 56% to 72% following the introduction of choice. This suggests that the introduction of choice has brought benefits in terms of accessibility. Table 3: Oxfordshire CCG Before the introduction of patient choice providers providers sites Number within 20-min drive of a site Number within 10-min drive of a site (90%) 55 (56%) After the introduction of (99%) 71 (72%) patient choice Note: a total of 99 GP operate in the area The above analysis does not recognise the presence of the Outside Clinic, which started to provide a domiciliary service in the area following the introduction of choice. We expect its presence to improve the overall accessibility of the service even further, especially for housebound patients. 11 Some of the sites belonging to Royal Berkshire NHS FT are located outside the CCG area (see Figure 6). 22

24 Figure 7: Oxfordshire CCG - accessibility before and after patient choice was introduced (GP within a 10-minute drive away of providers' sites) 12 Before the introduction of patient choice After the introduction of patient choice Providers before patient choice Id Providers after patient choice Id Oxford University Hospital NHS FT 1,2,3,4,7,8 Oxford University Hospital NHS FT 1,2,3,7,8,24 Royal Berkshire NHS FT 5,6,9,10,11, 12,13 Royal Berkshire NHS FT 5,6,9,10,11,12,13 Specsavers 4,14,15,23,27,28,30 Scrivens 16,17,18,19, 20,21,22,25, 26,29 12 This map shows the full range of sites contracted by Oxfordshire CCG. It includes sites that are contracted to provide services to patients within Oxfordshire CCG but which are located in other CCGs. For clarity we have not conducted an assessment of accessibility in neighbouring areas. We would expect such an assessment to identify a range of sites not contracted by Oxfordshire CCG and hence not listed above. 24

26 South Tees CCG and Hartlepool and Stockton-on-Tees CCG Prior to the establishment of CCGs, the former Stockton-on-Tees Teaching PCT, Middlesbrough PCT and Redcar and Cleveland PCT jointly commissioned adult hearing services. Since the former Hartlepool PCT arranged the service independently, we decided to exclude the correspondent area from this analysis. Following the introduction of patient choice, the two providers that were previously providing adult hearing services qualified. They provide services from 12 sites. In addition, the Outside Clinic, a domiciliary care provider was also qualified and available to patients in the area. Figure 9 shows the location of providers sites in the area. Figures 10 and 11 show the location of the 89 GP operating in the area and illustrates their proximity to providers sites. The actual number s within a 20-minute and 10- minute drive of a provider s site is presented in Table 4. Our analysis shows that services were already relatively accessible in the area before choice was introduced. Before choice was introduced, all GP were located within a 20-minute drive of a provider s site, and virtually all (98% ) were located within a 10-minute drive. In our view, it is not surprising that the introduction of choice has led to a limited increase in the number of providers. That said, the introduction of choice has led to the entry of the Outside Clinic, which started to provide a domiciliary service in the area. The above analysis does not recognise the presence of the Outside Clinic. We expect its presence to improve the overall accessibility of the service, especially for housebound patients. Table 4: South Tees CCG and Hartlepool and Stockton-on-Tees CCG providers providers sites GP within 20-min drive of a site GP within 10-min drive of a site Before and after the introduction of (100%) 87 (98%) patient choice Note: a total of 89 GP operate in the area 14 Additionally, since services in Hartlepool are now commissioned alongside those in Stockton-on- Tees and South Tees CCGs, patients in these two CCGs can access North Tees and Hartlepool NHS Trust, the provider formerly contracted by Hartlepool PCT. Further analysis has shown no improvements in accessibility coming as a result of this additional option. 26

27 Figure 9: South Tees CCG and Hartlepool and Stockton-on-Tees CCG - sites before and after patient choice was introduced Providers before and after patient choice Id South Tees NHS FT 1,3,6,9,10 Specsavers 2,4,5,7,8,11,12 27

28 Figure 10: South Tees CCG and Hartlepool and Stockton-on-Tees CCG - accessibility before and after patient choice was introduced (GP within a 20-minute drive away of providers' sites) Providers before and after patient choice Id South Tees NHS FT 1,3,6,9,10 Specsavers 2,4,5,7,8,11,12 28

29 Figure 11: South Tees CCG and Hartlepool and Stockton-on-Tees CCG - accessibility before and after patient choice was introduced (GP within a 10-minute drive away of providers' sites) Providers before and after patient choice Id South Tees NHS FT 1,3,6,9,10 Specsavers 2,4,5,7,8,11,12 29

30 Conclusions on the accessibility of adult hearing services for patients In North Norfolk, South Norfolk and Norwich CCGs accessibility has increased significantly. In fact, the number sufficiently close to at least one provider site has almost doubled after the introduction of choice. In Brighton and Hove CCG, the impact of the policy has been limited. The main reason is that the number of providers sites has changed slightly. Although, notably, our analysis does not show a reduction in the accessibility of services despite the local NHS hospital deciding not to apply to provide adult hearing services. The introduction of patient choice in Oxfordshire CCG has brought some improvements in terms of accessibility. In fact, a doubling in the number of provider sites has brought almost a 10% increase in the number s sufficiently close to at least one provider s site. In South Tees CCG and Hartlepool and Stockton-on-Tees CCG accessibility improved as a result of the addition of one provider offering domiciliary services in the area. The number of sites remained the same as prior to the introduction of choice, although our analysis shows that accessibility of services was already relatively high before choice was introduced. 30

31 Assessment on choice of providers In this section, in each of the four areas analysed, we examine whether patient choice has led to an increase in the number of options patients can choose from. We assess the options available to patients both in terms of individual provider sites and of distinct organisations that patients can choose from. We use the same drive-times adopted in the previous section as a threshold for options that are likely to be practical for patients to use. 15 The tables below show the options available to patients both before and after the introduction of patient choice in each area. North Norfolk, South Norfolk and Norwich CCGs Table 5 below shows that before patient choice was introduced, there were no GP within a 20-minute drive of two or more provider sites; this has increased to 83%of following the introduction of choice. Table 5: Before and after patient choice sites within 20-minute drive-time Before patient choice adult hearing providers (sites) located within the drive-time Number Share After patient choice adult hearing providers (sites) located within the drive-time Number Share % % % % % % % % % % % % % Total % Total % Table 6 shows that, prior to patient choice, there were no GP within a 20- minute drive away of two or more provider organisations. After the introduction of 15 Again, this analysis does not take into account those providers that operate a domiciliary service (eg the Outside Clinic). 31

32 patient choice, 73% are located within a 20-minute drive of two or more provider organisations. These results show that in North Norfolk, South Norfolk and Norwich CCGs, the range of providers and sites that patients can choose from has considerably improved. Table 6: Before and after patient choice organisations within 20-minute drivetime Before patient choice adult hearing providers (organisations) located within the drive-time Number Share After patient choice adult hearing providers (organisations) located within the drive-time Number Share % % % % % % Total % Total % Brighton and Hove CCG Table 7 shows that, prior to patient choice, about 74% in the area were located within a 10-minute drive of two or more provider sites. Following the introduction of choice, this has increased to 89%. Table 7: Before and after patient choice sites within 10-minute drive-time Before Patient Choice adult hearing providers (sites) located within the drive-time Number Share After Patient Choice adult hearing providers (sites) located within the drive-time Number Share % % % % % % % % % % % % Total % Total % 32

33 Table 8 shows that, prior to patient choice, only 7% in the area were located within a 5-minute drive away of two or more provider sites. After the introduction of choice, this has increased to 65%. Table 8: Before and after patient choice sites within 5-minute drive-time Before patient choice adult hearing providers (sites) located within the drive-time Number Share After patient choice adult hearing providers (sites) located within the drive-time Number Share % % % % % % % % Total % Total % Table 9 shows that, prior to patient choice, there were no GP within a 10- minute drive away of two or more provider organisations (only one organisation provided the service). Following the introduction of choice, this has increased to 94%. Table 9: Before and after patient choice - organisations within 10-minute drivetime Before patient choice adult hearing providers (organisations) located within the drive-time Number Share After patient choice adult hearing providers (organisations) located within the drive-time Number Share % % % % % % Total % Total % Table 10 shows that, prior to patient choice, there were no GP within a 5-minute drive away of two or more provider organisations (only one organisation provided the service). Following the introduction of choice, this has increased to 59%. 33

34 These results show that in Brighton and Hove CCG, the introduction of choice has increased the number of different providers that patients can choose between. Table 10: Before and after patient choice organisations within 5-minute drivetime Before patient choice adult hearing providers (organisations) located within the drive-time Number Share After patient choice adult hearing providers (organisations) located within the drive-time Number Share % % % % % % Total % Total % Oxfordshire CCG Table 11 below shows that, before patient choice was introduced, about 35% in the area were located within a 20-minute drive of two or more provider sites; this has increased to 98% of following the introduction of choice. Table 11: Before and after patient choice sites within 20-minute drive-time Before patient choice adult hearing providers (sites) located within the drive-time Number Share 34 After patient choice adult hearing providers (sites) located within the drive-time Number Share % % % % % % % % % % % % % % % Total % Total %

35 Table 12 below shows that, before patient was introduced, only 2% in the area were located within a 10-minute drive of two or more provider sites; this has increased to 67% of following the introduction of choice. Table 12: Before and after patient choice sites within 10-minute drive-time Before patient choice adult hearing providers (sites) located within the drive-time Number Share After patient choice adult hearing providers (sites) located within the drive-time Number Share % % % % % % % % Total % Total % Table 13 shows that, before patient choice was introduced, about 18% in the area were located within a 20-minute drive of two or more provider organisations; this has increased to 91% of following the introduction of choice. Table 13: Before and after patient choice organisations within 20-minute drive-time Before patient choice adult hearing providers (organisations) located within the drive-time Number Share After patient choice adult hearing providers (organisations) located within the drive-time Number Share % % % % % % % % Total % Total % 35

36 Table 14 shows that, prior to patient choice, there were no GP within a 10- minute drive away of two or more provider organisations; this has increased to 65% of following the introduction of choice. These results show that in Oxfordshire CCG, the range of providers and sites that patients can choose from has considerably improved. Table 14: Before and after patient choice organisations within 10-minute drive-time Before patient choice adult hearing providers (organisations) located within the drive-time Number Share After patient choice adult hearing providers (organisations) located within the drive-time Number Share % % % % % % Total % Total % South Tees CCG and Hartlepool and Stockton-on-Tees CCG 16 Table 15 below shows that 97% are within a 20-minute drive of two or more provider sites. Table 15: Sites within 20-minute drive-time adult hearing providers (sites) located within the drive-time Number % % % % % % % Share 16 As in the accessibility assessment we excluded the area corresponding to the former Hartlepool PCT from this analysis. Nonetheless, choice in the area is likely to have improved due to availability of providers based in Hartlepool after the introduction of patient choice. No before and after comparison is provided as the same organisations operate the service from the same sites after the introduction of choice. 36

37 adult hearing providers (sites) located within the drive-time Number % % Total % Share Table 16 below shows that 76% are within a 10-minute drive of two or more provider sites. Table 16: Sites within 10-minute drive-time adult hearing providers (sites) located within the drive-time Number % % % % % % % Total % Share Table 17 below shows that 99% are within a 20-minute drive of two or more provider organisations. Table 17: Organisations within 20-minute drive-time adult hearing providers (organisations) located within the drivetime Number % % Total % Share Table 18 below shows that 76% are within a 10-minute drive of two or more provider organisations. 37

38 As already discussed, in South Tees CCG and Hartlepool and Stockton-on-Tees CCG, the range of providers and sites that patients can choose from has remained the same. 17 Table 18: Organisations within 10-minute drive-time adult hearing providers (organisations) located within the drivetime Number % % % Total % Share Conclusions on Choice of Providers Proximity to Patients In North Norfolk, South Norfolk and Norwich CCGs the range of providers and sites that patients can choose from has considerably improved. Prior to the introduction of choice, no GP practice was sufficiently close to more than one provider site or to more than one organisation. After the introduction of choice 83% are located within a 20-minute drive away of two or more provider s sites and 73% are located within a 20-minute drive away of two or more organisations. In Brighton and Hove CCG the introduction of choice has increased the number of different providers that patients can choose between. Before the introduction of choice only one organisation was operating the service, now three organisations are active in the area and 94% are located within a 10-minute drive away of at least two of them. Despite the local trust deciding to stop providing the service, the number of sites for patients to choose between has increased and all of them are now within the CCG area. With the introduction of patient choice in Oxfordshire CCG, choice of providers has considerably improved. 98% are located within a 20- minute drive away of two or more providers sites and 91% are located within a 20-minute drive away of two or more organisations. 17 See footnote

39 The number of sites to choose from in South Tees CCG and Hartlepool and Stockton-on-Tees CCG has remained the same. 18 However, all patients now have the option of choosing an additional provider that operates the service within their own home. 18 See also footnote

40 Annex 4: Analysis of commissioner data on waiting times for adult hearing services Introduction The length of time that a patient has to wait for an assessment and the fitting of hearing aids (ie waiting times) is one service feature which determines how easy it is for patients to access a service. The evidence we reviewed suggests that waiting times can be of value to patients. For example, the patient survey suggests that patients are more likely to be dissatisfied with the service if the wait for a hearing assessment takes longer than five weeks after the GP referral. 19 This note summarises the results of our analysis of waiting times for adult hearing services. It explores whether waiting times have fallen faster in areas that introduced patient choice compared with those areas that did not. This note is structured as follows. We first report the average time that patients had to wait to receive a hearing assessment in We then describe how waiting times have changed from October 2008 to July 2014 and analyse whether introducing patient choice has had an impact on waiting times. Background: 2006 to 2008 Evidence from DH shows that in November 2006 around 166,000 patients in England were waiting for an audiology assessment. Of these, over 108,000 had been waiting more than 13 weeks and over 80,000 more than 26 weeks. The same evidence shows that the expected average wait for an audiology assessment in December 2006 was weeks. 20 It is worth noting that the period measured in this data covers only part of the wait for treatment (the wait between GP referral and the hearing assessment). It does not include the wait between the assessment and the fitting of any hearing aid(s) that may be required (the referral to treatment waiting time, RTT). This means that waiting times for patients to receive a fitting will have been longer than weeks. These long waits were caused in part by a significant increase in the number referrals to audiology services as a consequence of the Modernising Hearing Aid Services (MHAS) programme. 21 This programme was sponsored by DH, and was intended to modernise hearing services across England. The main innovation in this 19 See the patient survey report, page DH, Improving access to audiology services in England, March 2007, page 3, / 21 House of Commons, Health Committee, Audiology services, fifth report of session , 16 May 2007, page 12, 40

41 programme was the introduction of digital hearing aids. The programme started in September 2000 and ended in 2005 when all providers of NHS services were able to offer digital hearing aids. Digital hearing aids are generally better performing and more comfortable to wear than analogue hearing aids. 22 Over time this led to increased GP referrals, not only of new patients but also of those who wished to switch from analogue hearing aids to digital ones. As a consequence, existing NHS audiology service providers received more GP referrals and were unable to treat these patients in a timely way. Waiting times grew as a result. In 2007, DH made funding available for audiology. Existing providers expanded capacity to meet the increased demand (eg new roles were created by providers; for example assistants were employed specifically to set up the test rooms, so that audiologists could concentrate on serving patients). 23 In addition, DH made funding available for the purchase of further capacity from the independent sector. 24 The increased capacity had a significant impact, and by the end of 2008 the average referral to treatment in audiology was on average between 6 and 10 weeks. 25 Waiting times since 2008 and following the introduction of patient choice In October 2008, DH started to publish data on RTT waiting times for direct access audiology in each commissioning area in England. 26, 27, 28 This information provides a good approximation of waiting times for adult hearing services 22 We acknowledge that digital hearing aids may not be better performing than analogue hearing aids in all cases. For example, a musician wrote to us saying that the current sound quality of digital hearing aids could be lower than analogue hearing aids when playing music. 23 House of Commons, Health Committee, Audiology services, fifth report of session , 16 May 2007, page 28, 24 DH, Improving Access to Audiology Services in England, March 2007, page 7, 25 Monitor analysis of NHS England s Direct Access Audiology Data. Data are available at: 26 Direct access audiology services are predominantly services for patients affected by age-related hearing loss. 27 In 2013, the responsibility for publishing these statistics transferred to the NHS Commissioning Board (NHS England). 28 Direct access audiology RTT data have been collected on a mandatory basis since April 2008 and have been published since October This data does not include the entire population of patients accessing direct access audiology services. It excludes those patients that, even if sufficiently aged to receive a direct referral, have been first referred to an ENT department by their GP and then have been re-referred to an Adult Hearing Services provider. In addition, this data does not include information for those patients who failed to attend their first appointment. For these patients the referral is removed from the data, provided that the provider can demonstrate that the appointment was clearly communicated to the patient. 41

42 Unlike the pre-2008 data the information published from October 2008 onwards includes not only the time that patients had to wait to receive an assessment, but also the waiting time between the assessment and fitting. The RTT period ends with the fitting of hearing aids following the hearing assessment (or with the assessment if the patient does not require the fitting of a hearing aid). Data description and methodology In our analysis we use two sets of data collected by DH: completed pathways and incomplete pathways. 29 Ideally, to measure the average waiting times on a monthly basis it would be necessary to have information on the average RTT waiting time for the set of patients that is referred each month. However, we are not aware of a dataset that records this information. The completed pathways dataset measures the average RTT wait for those patients whose treatment was completed within the reporting month. 30 As a consequence, it does not provide any information on the length of wait for those patients who have not yet been treated (even if they have been waiting for more than 52 weeks). Using this dataset would mean that areas with large numbers of untreated patients might misleadingly appear to have short average wait. In contrast, the incomplete pathways dataset provides information on the length of wait for all patients who are still waiting for a treatment at the end of the reporting month. 31 While this is not an RTT waiting time it does include all patients and is therefore a more accurate representation of the average patient s experience of waiting times. The incomplete pathway dataset reports incomplete waiting times in weekly bands without specifying the exact number of days the patient has been waiting at the end of the reporting month. This means that if at the end of the month the patient has been waiting for 15 days or for 20 days this will in both cases be recorded as 2 3 weeks. We approximate the length of the wait to the weekly mid-point. For example, 29 See NHS England, Direct Access Audiology Data, 30 The length of the wait in the completed pathways dataset is measured from the date the referral takes place to the date where the patient receives the required treatment. The length of wait is reported in weekly bands (ie 0-1 weeks, 1-2 weeks, weeks, weeks, weeks, 52 weeks). If, for example, the referral is made on the 1 January 2011 and the fitting takes place on the 17 January of the same year, the length of the wait is 16 days and the patient will be reported as having waited 2-3 weeks. The incomplete pathways dataset reports each month the length of the wait so far for patients whose assessment has not occurred by the last day of the month. 31 The length of wait in the incomplete pathways dataset is measured from the date the referral takes place to the last day of the month. Again the length of wait is reported in weekly bands. If, for example, the referral is made on 1 January 2011 and the fitting has not yet taken place on 31 January of the same year, the length of the wait is 30 days and the patient will be reported as having waited 4 5 weeks so far. 42

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